Abnormal Pap Smear

Cervical Biopsy

Background - importance and magnitude of problem
Diagnostic goals - for overall category
  • Abnormal pap report
  • Inflammation
  • Papillomatous findings (HPV)
  • Atypical glandular hyperplasia (AGCUS)
  • Atypical squamous cells of unknown significance (ASCUS)
  • Low grade squamous intraepithelial lesion (mild dysplasia)
  • High grade squamous intraepithelial lesion (moderate, severe)
  • Abnormal Cervical Biopsy
  • Squamous metaplasia
  • Inflammation/cervicitis
  • Endocervical glandular hyperplasia without atypia
  • Endocervical glandular hyperplasia with atypia
  • Cervical intraepithelial neoplasia
  • Mild dysplasia
  • Moderate dysplasia
  • Severe dysplasia
  • Carcimona in-situ of cervix
  • Invasive squamous cell carcinoma of cervix
  • Invasive adenocarcinoma of cervix
  • Invasive adenosquamous carcinoma of cervix


Abnormal pap smears are relatively common and may be present in up to 5-10% of the population being screened. The report of an abnormal pap creates moderate anxiety for a woman because of the implication that it may represent cancer. In most cases however it does not represent cancer but rather irritations and pre-malignant changes that may need diagnostic workup and therapy to prevent cancer of the cervix.


The pap smear is a screening test and as such, it does not represent the gold standard of diagnosis. If the pap smear is abnormal, a biopsy is usually performed and that is the basis on which any treatment is prescribed. Pap smears may be reported as a worse grade than the actual cervical lesion or may be not as bad as the actual lesion.

It is also important to remember that pap smears may have as much as a 20-25% false negative rate; thus they can miss lesions. For that reason, a series of annual pap smears are recommended to decrease the likelihood that a false negative report is issued giving false reassurance that everything is normal.

Colposcopy is routinely used for management of abnormal pap smears because it indicates where to perform a biopsy that will yield the most abnormal changes on the cervix. Thus the biopsy that is obtained which is colposcopically directed is less likely to err in the direction of underestimating potential malignant change.

Cervical lesions

Background - importance and magnitude of problem
Diagnostic goals - for overall category
  • Anomalies
  • Developmental
  • Prenatal steroid exposure/DES related
  • Polypoid lesions
  • Endocervical polyps
  • Endometrial polyps
  • Prolapsed submucous fibroid
  • Papilloma virus
  • Inflammations, ulcerations and masses
  • Eversion/ectropion
  • Trauma
  • Herpes
  • Syphilis
  • Squamous cell carcinoma of cervix
  • Adenocarcinoma of cervix
  • Adenosquamous carcinoma of cervix
  • Cervical pregnancy
  • Old lacerations
  • Nabothian cysts


The cervix may often undergo trauma from both pregnancy, labor and delivery, and that associated with sexual relations. Lesions are not uncommon, however, most of them are benign.


Many cervical lesions are recognizable by an experienced observer and do not need further studies eg., Nabothian cysts, cervical lacerations, eversion, or condyloma acuminatum. Any lesion that is not readily identifiable, should be biopsied to make sure that there is not a malignant process present. Any visible polyps are removed even though they are rarely malignant. If polyps remain in place they will usually become ulcerated and eventually cause abnormal uterine bleeding.

Cervical discharge

Background - importance and magnitude of problem
Diagnostic goals - for overall category
  • Gonorrhea
  • Chlamydia
  • Non-Specific Cervicitis


Mucous is normally present in the cervix and is produced by endocervical glands. It is clear in color or an opaque grayish white. Cervical discharge is usually an observation of the examining physician rather than a patient complaint. On occasion, patients may complain of excessive vaginal discharge and the source of that is actually from the cervix.


Any cervical mucous that is yellowish in color, or not clear or opaque white, should have cultures taken. It may represent infection with sexually transmitted diseases.

Vaginal discharge and pruritus

Background - importance and magnitude of problem
Diagnostic goals - for overall category
  • Physiologic discharge
  • Non-specific bacterial vaginitis
  • Trichomonas vaginitis
  • Candida yeast vaginitis
  • Atrophic vaginitis
  • Foreign body vaginitis
  • Prepubertal gonococcal vaginitis
  • Allergic reaction
  • Rectovaginal fistula


Most women at some time in their lives will have one or more episodes of vaginal discharge with itching, or burning on the vulva. Vaginal infections are quite common and many over the counter remedies exist.


Most problems in this category should be specifically diagnosed in order to prescribe the most effective therapy. Most commonly diagnosis is performed by direct microscopic examination of the discharge suspended in saline. Occasionally cultures and other studies need to be performed. Chronic recurrent episodes of vaginal discharge are a much more difficult diagnostic category. Attention must be turned toward what is the cause of disruption of the normal vaginal flora which keeps vaginal infections from developing rather than what is the current infectious agent.